Serious Adverse Events @ Lakes DHB Hospitals 2012-13
21/11/2013 11:59:00 a.m.

Thursday 21 November 2013

Serious Adverse Events @ Lakes DHB Hospitals 2012-13

Lakes DHB Quality and Risk Manager Lesley Yule says Lakes DHB regrets any harm caused to patients during their care.

“Our staff are mindful of the patients and families involved in these incidents and we encourage families and patients to contact us to alert us to any issues that are noticed so we can act to prevent harm,” said Lesley Yule.

Lakes DHB serves a population of just over 100,000 people and had 68,001 contacts of hospital admissions and outpatients in the last year ended June 2013. (Comprised of: in-patients 25,636, and specialist outpatient attendances 42,365).

Reporting incidents is a voluntary process within the Lakes DHB.  This is a method of collecting incidents and near misses that have or have the potential to cause harm to our patients.   Our review into each incident assesses the seriousness and indicates the appropriate level of investigation to be undertaken, and our process is looking for accountability without blame.  This process is one of the fundamental tools in the health sector to improve safety, process and quality.

The last financial year Lakes DHB reported 18 adverse events to the Health Quality and Safety Commission. A total of 17 are reported for Lakes in the national HQSC report, with the difference being the result of a timing issue in finalising the level of harm for one case.  The 2012-13 events are an increase from the seven of the previous financial year.

As noted throughout the country, increased reporting is thought to be due to the New Zealand health sector’s move towards a culture of no blame.  This is to be encouraged as along with allowing Lakes DHB to learn from the mistakes, it allows for the outcomes of the improvements to be shared with all other health providers in New Zealand.

The make up of reported events in Lakes is as follows:
Falls with harm                                     5
Medication error                                    3
Delay in diagnosis and treatment     3
Pressure sores                                     2
Death of a baby during or following child birth 2
Patient behaviour causing harm        1
Inappropriate transport                        1
Discharged home with no known cause for clinical presentation. 1

Five of the patients who were affected by these events died as a result of the event.

Of this year’s events two were what are termed near misses - incidents that occur that could have had a serious outcome but did not.

All these events are investigated using a root cause analysis methodology, which results in identifying system errors and develops recommendations for improvements.

Falls are identified as the major risk for our patients when they are admitted to hospital. A change of environment for the elderly and confused adds to the likelihood of a fall so staff have a predetermined tool to assess the falls risk and a number of strategies to put in place to minimise that risk.  Working with the other regional DHBs, Taranaki, Waikato, Bay of Plenty and Tairawhiti, Lakes DHB has embraced the Open for Better Care campaign and the six-month programme of falls prevention.

Click here to read about the red socks initiative at Lakes DHB.

And click here to go to the HQSC website.

The prevention of falls will be a continuing part of the safety programme at Lakes and the next steps of the campaign will see us working with community health care providers, families and whanau to help prevent such accidents.

Medication errors are an international event and Lakes has three major errors this financial year. One of these errors resulted in death, due to inadequate monitoring of the side effects of the drug in the community.

The root cause analyses for drug errors have resulted in a number of improvement actions.

One incidental finding from these reviews found a patient who had a complex medication regime who took an over-the-counter cough mixture which led to her death. As a result of this finding the DHB has published information for patients in the community who are taking very strong pain relief warning them of the dangers of adding other medications to the mix.

Click here to see the brochure on Opioid Pain Relief.

Delay in diagnosis or treatment resulted in three serious adverse events. Two of these prolonged the patients’ treatment and delayed recovery. One had no serious harm but was reported and investigated as another result from the delay could have caused harm.

Hospital acquired pressure ulcers can be debilitating and cause loss of limb. The two cases reported by Lakes DHB were caused through a mechanical device used to prevent deep vein thrombosis following surgery. Through a hospital-wide project on the prevention of venous thrombosis the decision was made for mechanical foot pumps to no longer be used, with risk assessment and the use of preventative medication now used in place of the foot pumps. The best means of preventing this complication is ensuring patients are as fit as possible for surgery, with as short a time in theatre as possible along with getting the patient out of bed and walking on the same day or morning after surgery. A project underway in the DHB is Early Recovery After Surgery (ERAS) which looks at a number of ways to prevent complications and reduce recovery times.

The loss of a mother or baby during child birth or as a result of child birth is a very distressing event. Lakes DHB reports two unexpected baby deaths this year. While both these babies succumbed to difficulties during the labour there were lessons to be learned about the observations and actions taken during the time in labour. A heart monitor was purchased for theatre, guidelines were established regarding criteria for performing an emergency caesarean section, and there has been a change in protocol of managing a baby delivered unwell with the immediate involvement of a doctor.

Lakes DHB did experience a fire in a patient area due to a patient’s behaviour. A full review of the circumstances, clinical care and a review with the fire service revealed a number of improvements in monitoring equipment, checking possessions brought into hospital, and the need to advise relatives and friends about not bringing certain things into patients. The report on this event was shared with all DHBs and with the Department of Corrections as a learning.

Transportation between health centres can be a cause for concern and this incident was a near miss that was investigated to prevent a serious event from occurring. Work continues with staff to recognise appropriate streams of intervention, transferring quickly or stabilising the patient with the staff available and the support of a secondary or tertiary hospital. Support can be provided by tele and video links and this is to be enhanced in the near future at Lakes DHB. 

Please click here to view the Lakes DHB Quality Account for the period 1 July 2012-30 June 2013. This document details some of the many quality improvements undertaken at Lakes DHB to enhance safety and the care delivered to our community.